Frequently Used Forms
Please click on a form below to view a PDF printable version.
Behavioral Health Prior Authorization Form
Behavioral Health Therapy Prior Authorization Form (Autism)
Applied Behavior Analysis Referral Form
Q3 2020 PA Code Matrix
Q2 2020 PA Code Matrix
Q1 2020 PA Code Matrix
Q4 2019 PA Code Matrix
Q3 2019 PA Code Matrix
Q2 2019 PA Code Matrix
Q1 2019 PA Code Matrix
Q4 2018 PA Code Matrix
Q3 2018 PA Code Matrix
Q2 2018 PA Code Matrix
Q1 2018 PA Code Matrix
Continuity of Care Form
Prior Authorization 2018 Guide
Prior Authorization 2019 Guide
Prior Authorization 2020 Guide
Prior Authorization 2020 Guide v2
Complex Case Management - External CM Referral Form
Case Management Referral Form
Behavioral Health Coordination of Care Form
Health Education Referral Form [Direct Providers | IPA Medical Group]
Physician Certification Statement
Verio Healthcare Provider Request Forms for DME Equipment and Supplies
Other Forms and Resources
Medi-Cal Non-Covered Services
Member Grievance Form (English)
Member Grievance Form (Arabic)
Member Grievance Form (Chinese)
Member Grievance Form (Hmong)
Member Grievance Form (Russian)
Member Grievance Form (Vietnamese)
Member Grievance Form (Tagalog)
Allowed In-Office Lab Test List, effective 5-15-2018
Contracted Providers Making Changes
Membership Panel Form
Health Education Forms
Health Education Referral Form Direct Providers Only
Health Education Referral Form IPA Providers Only
Health Management Services Flyer (for Members only)
Health Education Services Provider Resources Flyer (for Providers only)
Cultural & Linguistic Services Forms
Staying Healthy Assessment Requirement
This requirement applies to all managed Medi-Cal members.
The initial health assessment includes the Initial Health Education Behavioral Assessment (IHEBA) which utilizes the “Staying Healthy Assessment”(SHA) form. The SHA forms are produced by DHCS and consist of 9 specific age categories (0-6 months, 7-12 months, 1-2 years, 3-4 years, 5-8 years, 9-11 years, 12-17 years, adult and seniors).
The assessment is designed to be completed by members age 12 and over and by parents for ages 11 and under, while waiting for their medical visit. If a member or parent requests help with completion, it must be provided. This assessment is designed to initiate dialogue between member and provider facilitating focused health education counseling addressing health behavior change.
This assessment must be completed with all new members within 120 days of enrollment into the plan. It must also be done with all existing patients at their next non-acute care visit and when entering into a new age category.
Staying Healthy Assessment Resources
Staying Healthy Assessment Forms ()
See links below for Staying Healthy Assessment forms in English, Spanish, Arabic, Farsi, Khmer, Somali, Armenian, Chinese, Hmong, Korean, Russian, Tagalog and Vietnamese
If you are unable to access the forms please contact your Provider Services representative.
Alternative Forms or Electronic Formats
If you are planning to use an alternative to the SHA forms and/or converting the SHA forms into an electronic format, please complete the request form below and submit it to Molina at least one month before using the alternative form(s).
Smoking Cessation Resources
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